Abolish user fees?
Many international non-government organisations (NGOs) have campaigned for abolition of user fees. See articles by the Bretton Woods Project; Global Health Watch; Health GAP Coalition / Global Treatment Access Campaign; Save the Children; and World Vision. Arguments for abolishing them focus on the large decreases in utilisation rates which have sometimes followed the introduction of fees, and on evidence that they worsen the impoverishing effects of seeking health care.
The widespread failure of fee exemption mechanisms for the poor has meant that, in some countries, abolition is seen as the only viable way to avoid making poor people pay fees. Additional charges against them include that they act as barriers to the MDGs and to the fulfilment of the right to healthcare (see the 1948 Universal Declaration of Human Rights).
However, there are reasons why many governments and health centres are reluctant to abolish fees. Focusing on user fees may do little to improve access as there are usually other, greater financial barriers, such as purchasing drugs, unofficial fees, and transport.
Fees also tend to be popular with health workers and district administrators because of the discretionary funds they provide. Although international financing may compensate in the medium term, governments will eventually need to draw on other sources, such as tax or insurance, which is often difficult in African and Asian countries. Even if they are able to do this, the financial management difficulties which stop this money from reaching the local level may not be easily resolved.
Another reason for not abolishing fees is a recent shift towards an emphasis on risk pooling through health insurance. See the 2000 World Health Report, Who pays for health systems? Voluntary insurance schemes require some form of payments for services to be in place – otherwise there is little incentive for people to make contributions.
Ultimately the decision to abolish or keep fees has to be made as part of broader health sector financing policy, and from the point of view of a developing country government it also depends upon donor support. The following sections suggest measures which will maximise the gains from whichever user fees policy is adopted, and considers what stance donors should take towards them.
The widespread failure of fee exemption mechanisms for the poor has meant that, in some countries, abolition is seen as the only viable way to avoid making poor people pay fees. Additional charges against them include that they act as barriers to the MDGs and to the fulfilment of the right to healthcare (see the 1948 Universal Declaration of Human Rights).
However, there are reasons why many governments and health centres are reluctant to abolish fees. Focusing on user fees may do little to improve access as there are usually other, greater financial barriers, such as purchasing drugs, unofficial fees, and transport.
Fees also tend to be popular with health workers and district administrators because of the discretionary funds they provide. Although international financing may compensate in the medium term, governments will eventually need to draw on other sources, such as tax or insurance, which is often difficult in African and Asian countries. Even if they are able to do this, the financial management difficulties which stop this money from reaching the local level may not be easily resolved.
Another reason for not abolishing fees is a recent shift towards an emphasis on risk pooling through health insurance. See the 2000 World Health Report, Who pays for health systems? Voluntary insurance schemes require some form of payments for services to be in place – otherwise there is little incentive for people to make contributions.
Ultimately the decision to abolish or keep fees has to be made as part of broader health sector financing policy, and from the point of view of a developing country government it also depends upon donor support. The following sections suggest measures which will maximise the gains from whichever user fees policy is adopted, and considers what stance donors should take towards them.
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